Perinatal Nurses Advocating for Bereavement Care for Women who Miscarry in the Emergency Department

by, Joyce Merrigan, RN

“If we don’t do it……it will never be done.”

The image will be forever ingrained in my memory: the remains of a miscarriage scooped up by a gloved hand in the emergency department,  tossed into a plastic specimen container and left on a counter. No condolences were offered to the woman who had experienced this loss. This memory haunts me to this day but also drives me to advocate for change.

“If we don’t do it……it will never be done.”

In the United States, 1 in 4 pregnancies ends in miscarriage. It is likely that you know of someone, or have personally experienced a loss. .  The gestational age at the time of pregnancy loss appears to determine not only the setting for care, the emergency department (ED) or labor and delivery (L&D), but also the standard of care when it comes to addressing bereavement. This difference demonstrates that miscarriage continues to be treated as a physical complaint and is not acknowledged as the loss of life with emotional dimensions.

Labor and delivery units across the country have incorporated evidence-based practice standards, educated the bedside nurses, and rewritten policy and procedures to apply the principles of perinatal bereavement care into the standard of care for women experiencing loss after 20 weeks gestation. We have done a terrific job responding to the unique emotional, spiritual and cultural needs of this population. However, there is another unique group of women who may be slipping through the cracks; women who miscarry before 20 weeks gestation and receive emergency care in our EDs.

“If we don’t do it……it will never be done.”

Historically nursing care of women experiencing a miscarriage in the ED concentrated on the medical interventions to correct hemodynamics and nursing care to promote physical recovery. The plan of care was devoid of bereavement support and the communication and activities to validate the miscarriage as the loss of life. Bereavement care acknowledges miscarriage as the loss of life and demonstrates that the products of conception need to be handled with respect and dignity. Bereavement care considers the spiritual, emotional and cultural expression of the pain that accompanies the loss of a baby.  The depth of this pain does not correlate with the duration of the pregnancy. It cannot be assumed that because it was an eight-week pregnancy, the woman will not mourn the loss. This stated we cannot conclude that all women who miscarry will cry or require perinatal bereavement support. However,  nurses must explore the personal meaning of the pregnancy loss being mindful of offering choices and accommodating individual requests.

The emergency department is fast-paced, has high nurse: patient ratios and often the standard operating procedure for the woman whose chief complaint is vaginal bleeding and not far enough along to send to L&D, is hemodynamic stabilization and discharge home.  Perinatal nurses are sometimes asked to tend to the emotional needs of a distressed woman in the ED. Although perinatal  nurses may happily accommodate the request, they may also be reluctant to leave the L&D unit and disrupt patient care there. ED and perinatal nurses working together in this regard could be viewed as collaborative but this approach can lead to fragmented care when women who are miscarrying are in need of continuity.

There are barriers to implementing perinatal bereavement care as the standard for women who miscarry in the ED. Besides time and culture, the most significant barrier is the inexperience with and knowledge of perinatal bereavement care communication skills and activities (Burkey, 2014; Chan, Chan, & Day, 2003; Evans, 2012; Rowlands & Lee, 2010; Zavotsky, Mahoney, Keller, & Eisenstein, 2013). Emergency nurses acknowledge they should provide specialized emotional care and support after a miscarriage but believe they lack the communication skills and knowledge to provide the best care (Chan et al., 2003). Fearful of saying something wrong, some ED nurses choose to remain silent, however, saying nothing may be as harmful as saying the wrong thing (Chan et al., 2003; Merrigan, 2016).

“If we don’t do it……it will never be done.”

The good news is there is a solid correlation between the comfort and ease in the delivery of perinatal bereavement support and formal education in the principles and methodologies! The ED nurse could be best prepared to meet the individual emotional, spiritual and cultural needs of these families if they had the opportunity to participate in a formal perinatal bereavement care education program (Evans, 2012). And who is better suited to lead this education but  perinatal nurses. After all, if we don’t do it, will it ever  be done?

Joyce  is a NCC certified OB RN and bereavement care coordinator. She presented perinatal bereavement care in the labor and delivery and most recently emergency room setting throughout the State of NJ. NJ MCH Consortia Perinatal Bereavement Committee and Fetal Infant Mortality Review Committee. Member of Organization of Nurse Leaders, NJ, ANA, NJNA, AWHONN, Hospice & Palliative Nurses Association (HPNA), Pregnancy Loss & Infant Death Alliance (PLIDA) and National Perinatal Association (NPA). She is currently pursuing her certification in perinatal loss (CPLC) through the Hospice & Palliative Credentialing Center (HPCC) and is also a fulltime DNP student focusing her doctoral project on the principles and methodologies of perinatal bereavement care for ED nurses with specific application to miscarriage.

References

Bereavement and Advance Care Planning Services Gundersen Lutheran Medical Foundation, Inc. (2008). RTS bereavement care training in early pregnancy loss. In M. Daley & R. Limbo (Eds.), RTS bereavement training in early pregnancy loss, stillbirth, and newborn death (7th ed.). La Crosse, Wisconsin: Bereavement and Advance Care Planning Services Gundersen Lutheran Medical Foundation, Inc.

Burkey, D. (2014). Evidence-based perinatal bereavement education for women treated for miscarriage in the preadmission testing unit: A pilot of system change. Available from ProQuest Dissertations & Thesis Global (1528574664). Retrieved from http://search.proquest.com.library.capella.edu/docview/1528574664?accountid=27965

Canadian Paediatric Society Statement. (2001). Guidelines for health care professionals supporting families experiencing perinatal loss. Paediatric Child Health, 6(7).

Carlson, R. (2012). Helping families create keepsakes when a baby dies. International Journal of Childbirth Education, 27(2), 86-91.

Chan, M., Chan, S., & Day, M. (2003). A pilot study on nurses’ attitudes towards perinatal bereavement support: A cluster analysis. Nurse Education Today, 24, 202-210.

Conry, M. J., & Phil Prinsloo, D. C. (2008). Mothers’ access to supportive hospital services after the loss of a baby through stillbirth or neonatal death. Health S. Gesonheid, 13(2), 14-24.

Evans, R. (2012). Emotional care for women who experience miscarriage. Nursing Standard, 26:42, 35-41.

Gundersen Lutheran Medical Foundation, Inc. (1984-2013). Resolve through sharing bereavement education model position paper [Position paper]. Retrieved from Gundersen Health website: http://www.gundersenhealth.org/upload/docs/Bereavement/RTS-PPA-Educational-Model.pdf

Hannah, K., & Goodall, U. (2013). Perinatal bereavement care: Are we meeting family’s needs?. British Journal of Midwifery, 21:4, 248-253.

Kobler, K., & Limbo, R. (2011). Making a case: creating a perinatal palliative care service using a perinatal bereavement program model. The Journal of Perinatal & Neonatal Nursing, 25(1), 32-41.

Merrigan, J. L. (2016). Perinatal bereavement care for women who miscarry in the emergency department. Unpublished manuscript, School of Nursing and Health Sciences, Capella University, Minneapolis, MN.

Rowlands, I., & Lee, C. (2010). ’The silence was deafening’: Social and health service support after miscarriage. Journal of Reproductive and Infant Psychology, 28(3), 274-286.

Zavotsky, K., Mahoney, K., Keller, D., & Eisenstein, R. (2013). Early pregnancy loss and bereavement in the emergency department: Staff and patient satisfaction with an early fetal bereavement program. Journal of Emergency Nursing, 39(2), 158-161.

40 thoughts on “Perinatal Nurses Advocating for Bereavement Care for Women who Miscarry in the Emergency Department

  1. Jennifer Ryan RNC-OB says:

    Very important to nursing and patients. Personally I had an awful experience with an early miscarriage that left me lost and suicidal. No one gave me resources to deal with the loss of my precious baby. My emotional needs and the grief process were not addressed. This is very important research.

    • Joyce Merrigan, BSN, RNC-OB says:

      Jennifer,
      Thank you for sharing your thoughts. I truly appreciate that you have provided validity to this topic. It is the stories of women such as yourself that ignite me to pursue this change.

    • Anita Catlin says:

      For those interested in the topic of miscarriages and the Emergency Department, a national meeting is being held. On April 27 in Houston, Texas, the National Perinatal Association is sponsoring a workshop to create interdisciplinary guidelines for care in the Emergency Department. Professional representatives from AWHONN, ACOG, PLIDA, NPA and many others will sit down with representatives from the Emergency Department Physician and Nursing Organizations to attempt to solve this problem. All interested parties are invited to attend. Contact http://www.nationalperinatal.org/2016agenda

  2. Beth says:

    I was just involved in a case like this. The young woman brought in an under 15 week miscarriage to the ED and was sent home to deliver placenta without going to our L&D. She entirely skipped our usual breavement process. Later she called from another hospital where she had had a D&C. They wanted the miscarriage to have a cremation/memorial service. Fortunately the miscarriage was still in Path. It was a good catch. ED needs to be more aware of potential bereavement needs and i agree collaboration or at least education sent home w the patient is a start.

    • Breann says:

      You say “the miscarriage was still in Path”. Does the miscarriage refer to the baby? I think that language is a shift that needs to happen. It’s a baby, not a miscarriage.

      • patchoulidaughter says:

        Hi Breann, I agree the language is incredibly upsetting. I think that the ethical framework around voluntary abortion makes the language change all but impossible though.
        Walking into one room and referring to a loss as a baby and another as a product of conception, is a difficult tightrope to walk. It’s really the problem with legal recognition of babies under 20 weeks gestation too, it’s a challenge to legal abortion.

  3. Shirley says:

    It is necessary to support a patient in their loss and to not let it remind them of terrible care along with the loss. No matter where it occurs. Steps to insure respect and sympathy. Every area of care should be able to do this.It makes a difference.

    • Joyce Merrigan, BSN, RNC-OB says:

      Shirley,

      You are so right. Thank you for your response. We can and we will make a difference! I do understand that it is not a realistic expectation for emergency room nurses to provide the full range of perinatal bereavement care activities. However, providing specific education will promote their autonomy and go a long way in adapting the perception of miscarriage to include the emotional and spiritual consequences in addition to the physical emergency.

  4. Rana Limbo says:

    Thank you, Joyce, for reminding us that care still needs improvement. Jill Wilke, MS, RN, CPLC, is a former ER nurse, current Resolve Through Sharing (RTS) national faculty member, and former RTS lead educator. She will be speaking at the International Perinatal Bereavement Conference, sponsored by the Pregnancy Loss and Infant Death Alliance (PLIDA), on September 28 in Phoenix (www.perinatalbereavementconference.org). Considered a leader in emergency room care, care we consider an “emotional emergency,” Jill possesses a high level skill set and amazing speaking abilities. Thank you for recognizing the RTS manual, as we have had a standard of care for miscarriage, including the emergency room, since the 1980s. The standard includes communication, supplies, written information, relational support, follow-up, and a check list.

    • Joyce Merrigan, BSN, RNC-OB says:

      Dr. Limbo,

      I am humbled by your response to my blog and I am very familiar with your work since I have drawn upon your research and the RTS model for my own scholarship and practice. I share your passion to improve the emotional care of women and their families who experience the loss of a pregnancy and look forward to implementing my DNP project that concentrates on perinatal bereavement care for women who miscarry in the emergency department. We have much work to be done but we have come a long way thus far!

      • Rana Limbo says:

        I so look forward to hearing about your DNP project final results. You have chosen such an important topic and your work and writing will help so many women get the care they need and deserve. I hope that we can keep in touch–I know you will help us learn and grow in our knowledge and skills. Women and their families experiencing a miscarriage need their health care providers to be interested in what each of them is thinking, feeling, and what their goals are. For that, developing a relationship that shows we care is both essential and supportive. With deep respect.

  5. Sherry says:

    What was described in the first paragraph happened to me. So I lay there, in shock, looking at my baby in what looked like a deli container on the counter. I hadn’t even been allowed to hold or touch it.The nurse had labeled it ‘medical waste’. When the doctor finally walked in, he glanced over and said ” Damn! That’s a big fetus.” then when I asked for a few moments alone with my husband, the doctor got angry and left the room. A few minutes later a nurse came in, disconnected my IV, and said ” You know you’ll be back here within a day or two, probably with an infection.” I asked what she meant, and she said ” The doctor said you were being uncooperative and wanted to leave.” That was 22 years ago, and I am so glad there are some finally realizing that even in an ER environment, women need compassion.

    • jmerriganblog says:

      Sherry,
      I am saddened by your experience. Thank you for having the courage to share. Please find comfort in the knowledge that stories such as yours create the momentum needed to drive change in practice. Myself and so many others, will carry your story in our minds as we continue to advocate for this change.

  6. Nancy says:

    I was new in town, my husband was out of town traveling for business when I started cramping and bleeding at 16 week pregnancy…I went to an urgent care because I didn’t know where a hospital was. We lived outside of Louisville, Kentucky… The doctor at urgent care came in the room with me laying on the bed and told the nurse, did not address me at all, saying I can’t do anything for her, sent her to the hospital…I explained I didn’t know where to go, afraid to drive in a strange city, and he told the nurse to give me a map and get me out of there….I was terrified and just went home….My husband came right home and we found a doctor to go visit next day….that night I did go into labor and we rushed to the hospital…I had passed a huge clot and was bleeding badly so very afraid of hemmoraging, heard from a friend that I could bleed to death in minutes so having all this in my head I agreed to a D&C when at hospital….I have so much regret!!!! I wish I would have understood that I could have had the baby in tact and looked at baby and touched my baby and held my baby no matter how small baby was….I suffered many nightmares, vivid nightmares, even one where when people would ask to see my baby I would take It out of my pocket to show them…my baby never had a face because I didn’t know what sex it was after D&C……..all of this was 31 years ago and every minute of three days is vivid in my memory like it was yesterday!! I quietly celebrate baby’s death and birth that was my due date……..I look forward to meeting my baby in heaven

    • Joyce Merrigan, BSN, RNC-OB says:

      Nancy,

      I am saddened to hear about your experience. Thank you for having the courage to share this so vividly. Please find comfort in the knowledge that your story adds to the momentum needed to drive change in practice. I will personally recall your story as I continue to advocate for this change.

  7. Eileen says:

    The Loss of Loved Ones to Sudden Tragedy (LLOST) Foundation’s current goal is to help educate the “first responders” on perinatal bereavement. Please let me know how we can help. Eileen Reichler, Co-Founder of LLOST

  8. Eileen Reichler says:

    The Loss of Loved Ones to Sudden Tragedy (LLOST) Foundation’s current goal is to help educate the “first responders” on perinatal bereavement. Please let me know how we can help. Eileen Reichler, Co-Founder of LLOST (www.LOST.org)

  9. tania rendon says:

    One of the best articles that i have seen written on the subject of miscarriage. Thank you for bringing awareness. It has been my goal (and my husband’s) to share our story with others so they too can heal from what has happened to them. We have had 3 miscarriages. One experience we were treated with dignity and respect. The other two we were given (some) care at the ER. But no condolences. I was just a number in a room. We never found out the sex of our second baby when they were supposed to tell us. It has taken years to process and still the hurt remains. And yes our baby’s remains were treated as tissue and to this day haunts us.

  10. jmerriganblog says:

    Tania,

    Thank you for sharing your story. I am so sorry for your losses. Please find comfort in knowing that your efforts are the driving force behind this change! Together, we CAN make a difference! I am very curious to understand the differences in the care you received with each loss and what you and your husband feel helped you and what you feel remains a barrier to your healing. Please feel free to reach out to me again Tania.

  11. Chelsie says:

    This sounds like a wonderful movement. I wish I had known better who to contact and what to do.
    I had been married for a year and pretty young when I lost our first baby. I called my Mum in law, as she had many children and miscarriages.. I asked her if I should go to the doctor or the hospital and she said they wouldn’t do anything so I should stay home.
    Part of me wonders if she answered that way, while she was still caring in in words and tone, because of how she had been treated? If perhaps her babies as just been treated as another medical proceeder? Realistically, I know there probably wasn’t a lot to be done..
    It’s been nearly 6 years and I wish I had known differently, that maybe if I had gone to hospital I could have passed my tiny (maybe only 6 weeks at most) baby and actually respectfully placed them to rest if possible. Or at least known better how to take care of myself at home.

    I am thankful that there are many in the medical profession who care about the hearts of those who’ve lost the little babes they won’t fully know, but do fully love.

  12. Toni says:

    Thank you for this article. You have given me the words to describe the type of work I want to go into when I finish my degree as a social worker. I know it won’t be as a nurse, but with extra training to specialise, working with families who lose their baby to miscarriage, still birth or neonatal death such as SIDS, is where I want to work. Knowing the phrase “perinatal bereavement” has given me a better way to describe what I want to do.

    For the families whose babies have died, I’m so sorry for your losses. My own mother had seven miscarriages at different ages and the least supportive person turned out to actually be her husband, my father. My sincerest of condolences to you all

  13. Cathy Benavidez says:

    Amen. It all starts with the ER doctors who look at a loss before 20 weeks as tissue, send it to the lab as specimen and say, next…I am no longer in the perinatal field but strongly believe as a Social Worker that regardless of the weeks of gestation a women who has lost her pregnancy has lost ” HER BABY”, she is grieving,as is her family. She needs to be treated with dignity and respect, no different then working with someone who has a still birth or loses a child. Loss is loss and grief is grief. I remember going at all hours of the night because it was important to me to be there to offer comfort, answer questions, offer choices, take pictures, offer a prayer or a blessing and give a memory box if they accepted to be given one. Some need and want resources some not. I can’tell tell you how many times I took a mom, significant other or an entire family to the path lab to view the fetus. That is not were this should be taking place or how many times the path lab would call to say the fetus was more then 20 weeks and needed to have some type of service. This happened because the ER never called a social worker and just sent the fetus to lab.

  14. Amy says:

    Joyce, I was very interested in reading your article. I volunteer with a group called Teeny Tears. We make tiny diapers for still born babies. We also provide Mini Blankets with hats for losses as small as 14 weeks. I often call hospitals to offer our free clothing. Usually the tiny diapers for 18-32 weeks gestation are well received.I find that although there is much improvement to be made, a good percentage of L&Ds do have some sort of bereavement program. When I ask about the smaller, 14-18 week items the responses are varied. A few hospitals have great communication with the ER and wonderful programs set up. Many are grateful for these special little items. But in my experience, many also respond “we never see those here” or “those women are usually sent home” or one of the worst, “well, to tell you the truth, THOSE ones(the little babies) usually end up in the toilet.” and then refusing the offered tiny blankets and hats. We know how important the treatment at the hospital is for the emotional recovery of the family. I have read some absolutely heartbreaking stories from other loss moms since I had my own little one stillborn at full term. Any improvements that can be made would be welcomed, because unfortunately this is a constant need. You are doing a wonderful thing and I wish you the best with it.

    • Ann Coyle says:

      Amy,
      I am just working my way into the ED to work with Moms with early losses. Our hospital does send Moms as early as 15-16 weeks to the Labor and Delivery unit usually, but the earliest ones still go to the ED. I would love to provide those nurses with any keepsakes to help the families through this difficult time.

        • Ann Coyle says:

          Could you send me supplies for 30-40 until I get their ‘buy in’ on this new endeavor? My address at work is
          Ann Coyle
          100 Bowman Dr
          Voorhees,NJ 08043
          Can anyone share with me what your hospital does with miscarriage remains? How are they disposed of? Do you have any type of service? Can parents bring the baby back for respectful disposition from home? Just trying to get our hospital in board with respectful disposition. Thanks!!

        • jmerriganblog says:

          Good morning Eileen!

          I am so pleased that you reached out to respond to my blog once again. I attempted to reach you via your website but was unable to connect. Next month I begin my doctoral project providing RTS training for emergency room nurses and evaluating their confidence in providing perinatal bereavement care to women who miscarry. Please email me at joyce.merrigan@yahoo.com. I would be honored to incorporate LLOST Foundation supplies. I look forward to connecting soon!

          Joyce

  15. Anita Catlin says:

    A National Meeting to discuss this topic will occur on April 27 in Houston Texas. Leaders from AWHONN, ACOG, PLIDA and other organizations will sit down with representatives from the American College of Emergency Physicians, American Academy of Emergency Medicine, and the Emergency Room Nurses Association to work out guidelines for practice. All are invited to attend. http://www.nationalperinatal.org/2016agenda

    • jmerriganblog says:

      Good morning Anita!

      The NPA meeting provided the forum for ground breaking multidisciplinary collaboration and I am very proud to have been a participant! Congratulations to you and the entire group on reaching consensus on the NPA Position Statement which provides guidelines for perinatal bereavement care for women who miscarry in the emergency department. This Blog would be a wonderful arena for dissemination!

      Joyce

  16. Anita Catlin says:

    There will be a national meeting in Houston. Texas, on this topic, on April 27, sponsored by the National Perinatal Association. Representatives from AWHONN, ACOG, PLIDA and others will sit down with representatives from the American College of Emergency Room Physicians,
    American Academy of Emergency Medicine and the Emergency Room Nurses Association to craft improved policy and procedure for losses in the ED. If this is an area of interest for you, you are invited to attend. http://www.nationalperinatal.org/2016agenda
    Anita Catlin

  17. Kate says:

    Hi Joyce,
    Great article.
    I am actually waiting for a publication of a study to come out that I did. Its called “Miscarriages and the emergency department: a qualitative study”. I interviewed women who had this experience for my masters thesis. Send me an email and we can chat more. I think you’ll enjoy reading it.
    Kate

    • jmerriganblog says:

      Good morning Kate!

      I would enjoy connecting with you and reading your publication! Please feel free to reach me at joyce.merrigan@yahoo.com. Thank you for your comment and the work you’re doing in this area. My doctoral work focuses on perinatal bereavement care education for emergency room nurses. Although there are several, formal education and confidence of the ER RN has been identified as the major barrier to incorporating bereavement care.

      Joyce

  18. Crystal says:

    I suffered a loss at 14 weeks. The fact that I was never allowed to see my baby, but saw them throw her in a cup, place a rubber glove over it, and carry her out of the room haunts me every single day of my life.

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